Intersection Syndrome of the First and Second Dorsal Compartments Injection

Other Names

• Intersection Syndrome Injection
• Injection of the First and Second Dorsal Compartment Intersection

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Background

Illustration of the crossover of the first and second dorsal compartment demonstrating the intersection area.

Key Points

• Needle: 25 gauge, 1.5 inch
• Transducer: high frequency, linear
• Find the second compartment, then slide probe proximal until you find the intersection
• Preferred technique is short axis, in plane

Anatomy of 1st and 2nd Dorsal Compartments

• Compartment 1 crosses obliquely and superficially over compartment 2
• Angle is approximately 60 in the distal forearm
• Approximately 4-6 cm proximal to Lister's tubercle

Palpation Guidance vs Ultrasound Guidance

• It is recommended that this injection be performed with ultrasound guidance
• There is no literature comparing palpation and ultrasound guidance

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Indications

• Intersection Syndrome

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Needle and probe position for short axis, out-of-plane technique

Ultrasound of short axis, out-of-plane technique. Dots represent needle vector

Needle and probe position for short axis, in-plane technique

Ultrasound view of short axis, in-plane technique. Needle vector represented by the white arrow.

Equipment

• Sterile including chloraprep, chlorhexadine, iodine
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Common ultrasound findings include:
  • Hypoechoic area between the intersection of the two compartments
  • Edema in the surrounding soft tissue
  • Thickening of the tendon sheaths
  • Color doppler may show hyperemia

Technique: Short Axis, Out-of-Plane

• Patient position
  • Seated/Supine
  • Forearm neutral on table
  • Radial aspect exposed to proceduralist
• Transducer position
  • Short axis to the intersecting compartments
• Needle Approach/ Orientation
  • Out-of-Plane
  • Distal to proximal or proximal to distal
• Target
  • Where compartment 1 crosses over compartment 2
• Pearls and Pitfalls
  • Once the needle is in the ideal location, consider rotating probe 90 degrees to confirm in long axis
  • Do not confuse the hypoechoic muscles for inflammatory fluid

Technique: Short Axis, In-Plane

• Patient position
  • Seated/Supine
  • Forearm neutral on table
  • Radial aspect exposed to proceduralist
• Transducer position
  • Short axis to the intersecting compartments
• Needle Approach/ Orientation
  • In-Plane
  • Radial to ulnar or ulnar to radial
• Target
  • Where compartment 1 crosses over compartment 2
• Pearls and Pitfalls
  • Needle has to track through more tissue with in-plane technique
  • Do not confuse the hypoechoic muscles for inflammatory fluid
  • Step-off can help

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Aftercare

• No significant restrictions
• Can augment with ice, NSAIDS
• Consider placement in a Cock Up Wrist Splint

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Complications

• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

• Procedures Main
• Ultrasound Main
• Hand Pain Main

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